We report a 5-year-old male child with a large lymphovascular malformation of the tongue presenting with signs of airway obstruction scheduled for bleomycin sclerotherapy and tracheostomy. Anesthetic concerns include limited mouth opening, airway obstruction, poor visualization, bleeding, and distorted anatomy, thereby rendering mask ventilation, laryngoscopy, intubation, and possible invasive airway access difficult. While awake airway management options are ideal for difficult airways in general, these techniques may be inapplicable to pediatric patients. Management options are further constrained in resource-limited clinical settings where critical equipment may be unavailable. By conducting a thorough preoperative evaluation and by adopting a multidisciplinary approach to case planning, preparation, and management, a strategy was developed, enabling successful airway management. The use of this approach may facilitate the successful anesthetic management of a difficult pediatric airway in austere clinical environments.